Optimal Approach to Small Unilateral Testicular Nodules-Can We Reliably Predict Tumor Histology Based on Size?

INTRODUCTION: We evaluated primary testicular tumor characteristics associated with nongerm cell tumor histology and potential appropriateness for testis sparing surgery in selected patients from our institution. METHODS: We retrospectively reviewed medical records of patients undergoing surgery for testicular masses between 2003 and 2015. We included patients with unilateral testicular tumors, normal preoperative serum tumor markers and no preoperative evidence of metastatic spread. Demographic and clinical information were extracted. The primary outcome studied was tumor pathology, germ cell tumor histology vs nongerm cell histology. We compared patients in these cohorts based on the testicular tumor size. RESULTS: A total of 48 patients met study criteria, 18 (37.5%) of whom had a final pathology consistent with nongerm cell histology. In general, the median tumor size was less in the nongerm cell group (11 mm vs 27 mm, p=0.001). Tumor size less than 2 cm was associated with increased likelihood of nongerm cell histology (p=0.003) with 61.9% of those with tumors less than 2 cm harboring nongerm cell tumors and therefore likely appropriate for organ-sparing surgery. A receiver operating characteristic analysis demonstrated a maximum sensitivity and specificity for selecting masses with normal tumor markers as having nongerm cell histology at a size cutoff of 18 mm. CONCLUSIONS: It appears that a majority of patients with localized small testicular masses and nonelevated tumor markers will have nongerm cell histology, which makes them potentially eligible for testicular sparing surgery at centers with expertise in intraoperative frozen section analysis.

Incidence and risk factors for positive urine culture at the time of pediatric urologic surgery.

PURPOSE: Urinary tract infections are relatively common in pediatric patients. Unrecognized bacteriuria at the time of urologic surgery puts patients at increased risk for perioperative complications. Many pediatric urologists obtain preoperative or intraoperative urine cultures prior to surgery, but data are lacking regarding rates and risk factors for positive intraoperative urine cultures. We conducted a retrospective cohort study of patients undergoing pediatric urologic surgery to examine factors associated with positive intraoperative urine cultures. MATERIALS AND METHODS: Charts of patients of age 0-18 years from a single pediatric urologist with associated intraoperative urine culture results between 2008 and 2013 were retrospectively reviewed. Demographics, prior culture results, and information regarding possible risk factors of interest-history of constipation, hydronephrosis, neurogenic bladder, posterior urethral valves, ureterocele, UPJ obstruction, urolithiasis, vesicoureteral reflux, and circumcision status-were collected and analyzed. RESULTS: Seven hundred and fifty procedure encounters with associated intraoperative urine culture results were reviewed. Overall positive urine culture rate was 13.5%. Factors associated with increased odds of positive intraoperative urine culture included neurogenic bladder (odds ratio 26.3, p < 0.001), prior positive culture (OR 5.4, p < 0.001), female sex (OR 2.1, p 0.007), constipation (OR 2.9, p < 0.001), and urolithiasis (OR 1.58, p = 0.04). Patients without any of these risk factors had no positive intraoperative cultures (p = 0.03). CONCLUSIONS: Patients with neurogenic bladder, prior positive urine culture, constipation, female gender, and urolithiasis were at increased risk for positive intraoperative urine culture. This may aid in decision-making regarding obtaining preoperative or intraoperative urine cultures in pediatric urology patients.

The effect of digital rectal exam on the 4Kscore for aggressive prostate cancer.

BACKGROUND: The 4Kscore is a new commercially available blood-based diagnostic test which predicts risk for aggressive, clinically significant prostate cancer on prostate biopsy. The 4Kscore is currently restricted to patients who have not had a digital rectal exam (DRE) in the previous 96 h, owing to prior mixed data suggesting that prostate specific antigen (PSA) isoforms may increase by a statistically significant-if not necessarily clinically significant-amount shortly after DRE. Our primary objective was to determine if 4Kscore test results are affected by a preceding DRE. METHODS: Participants at a Prostate Cancer Awareness Week screening event sponsored by the Prostate Conditions Education Council filled out clinical history questionnaires and had blood samples for 4Kscore testing drawn prior to DRE, then 15-45 min following DRE. Patients with prior cancer diagnosis, 5-alpha reductase inhibitor medication use, or lower urinary tract procedures in the prior 6 months were excluded, resulting in a population of 162 participants for analysis. Values were then compared to determine if there was a significant difference in 4Kscore following DRE. RESULTS: A statistically significant increase was seen in levels of 3 kallikreins measured (total PSA, free PSA, and intact PSA; median <0.03 ng/mL for all). This resulted in a small but statistically significant decrease in post-DRE 4Kscore (median absolute score decrease 0.43%). Using a 4Kscore cutoff of 7.5% resulted in reclassification of 10 patients (6.2%), nine of whom were "downgraded" from above the cutoff to below. CONCLUSIONS: If the blood draw for the 4 K score is performed after a screening DRE, there is a statistically significant difference in the 4 K score results, but in the vast majority of cases it would not affect clinical decision making.

Large Cystic Metanephric Adenoma in a 15-Year-Old Girl.

Metanephric adenoma is a rare pediatric renal tumor, generally considered to be benign. It can be difficult to distinguish from Wilms tumor and renal cell carcinoma based on imaging alone, and even may be difficult on histopathologic analysis. We present a case of a large cystic metanephric adenoma managed with surgical resection. This case highlights the difficulty in managing cystic renal lesions in children and adolescents as there is a paucity of data on the radiologic and pathologic correlation in such patients.